LARC for the Medically Complicated Patient
EXECUTIVE SUMMARY
Women with chronic medical conditions can safely use LARC methods. The U.S. Medical Eligibility Criteria from the CDC has been endorsed by the American College of Obstetricians and Gynecologists, and the evidence-based report finds few medical conditions that are absolute contraindications to LARCs.
- Many chronic medical conditions, such endometriosis, endometrial hyperplasia, polycystic ovarian syndrome, and sickle cell disease, improve when women use one of the LARC methods.
- An analysis of a nationwide healthcare claims database of reproductive-age women enrolled in private insurance during 2004-2011 indicates that despite the potential for serious maternal and fetal pregnancy-associated risks, contraceptive use was not optimal among women with medical conditions.
Half of all pregnancies in the United States are unintended; at the same time, more than 45% of all Americans suffer from a chronic disease.1 Chronic medical conditions can complicate maternal and fetal health during pregnancy, making unintended or mistimed pregnancy problematic.2 Results from a 2016 study indicate that fewer than 30% of females ages 14-25 years prescribed teratogenic medications also demonstrated documented contraceptive use.3 An analysis of a nationwide healthcare claims database of reproductive-age women enrolled in private insurance during 2004-2011 indicates that despite the potential for serious maternal and fetal pregnancy-associated risks, contraceptive use was not optimal among women with medical conditions.4
Family planning providers know that use of effective reversible contraceptives is important for women with health issues, yet sometimes those same illnesses make the contraceptives themselves less effective or less safe.
There is limited research on the use of contraceptive methods in women with medical problems, says Rameet Singh, MD, MPH, chief of the Division of Family Planning, Department of Obstetrics and Gynecology, at the University of New Mexico School of Medicine in Albuquerque. The current evidence supports safe use of long-acting reversible contraceptives (LARCs) in both healthy women and those with medical problems, she notes.
On the other hand, the alternative of pregnancy often poses a greater risk of morbidity or mortality in women presenting with medical problems, Singh says. Intrauterine devices (IUDs), in particular, offer low systemic exposure to progesterone through the levonorgestrel IUDs or no hormonal exposure via the copper IUD, she states.
“The U.S. Medical Eligibility Criteria from the CDC have been endorsed by American College of Obstetricians and Gynecologists, and the evidence-based report finds few medical conditions that are absolute contraindications to LARCs,” Singh says.
Check the Evidence
Because all LARC methods are estrogen-free, they often are a good class of methods for women whose medical conditions may put them at increased risk of arterial or venous thrombosis, says Courtney Schreiber, MD, MPH, associate professor of obstetrics and gynecology at the Hospital of the University of Pennsylvania in Philadelphia. Additionally, they are highly effective at preventing unintended pregnancy, which can be of particular importance for women with medical conditions who wish to maximize their health before becoming pregnant, she notes.
The recently updated U.S. Medical Eligibility Criteria (MEC) and Selected Practice Recommendations (SPR) offer guidance for the contraceptive management of these complicated patients. The 2016 U.S. MEC was updated to include the addition of recommendations for women with cystic fibrosis, women with multiple sclerosis, and women using certain psychotropic drugs or St. John’s wort, as well as revision of recommendations for women with known dyslipidemias, migraine headaches, superficial venous disease, gestational trophoblastic disease, factors related to sexually transmitted infections, and HIV.5 (For more information, please see the October 2016 Contraceptive Technology Update article, “Updates Issued For U.S. MEC and SPR: What Do the Changes Mean?” at: http://bit.ly/2dutOl1.)
Long-acting, highly effective contraceptive methods might be the best choice for women with conditions that are associated with increased risk for adverse health events as a result of pregnancy, the new MEC notes. These women should be advised that sole use of Tier 3 methods (condoms, female condoms, fertility-based awareness methods, vaginal sponge, and spermicide) might not be the most appropriate choice because of their relatively higher typical-use rates of failure, it states.5
Schreiber recently presented information on the use of LARCs in women with coexisting medical conditions in a webinar, “LARC for the Medically Complicated Patient,” sponsored by ACOG. One case study featured a young woman in her 20s with cystic fibrosis (CF). According to research, women with CF experience a relatively high rate of unplanned pregnancy and do not receive optimal advice or use the full range of contraceptive methods.6
Patients with CF are at increased risk for diabetes, liver disease, gallbladder disease, and venous thromboembolism (particularly related to use of central venous catheters), and are prescribed antibiotics frequently. Categories assigned to such conditions in U.S. MEC should be the same for women with CF who have these conditions, the guidance notes. For CF, classifications are based on the assumption that no other conditions are present; these classifications must be modified in the presence of such conditions, it advises.
For women with CF, combined oral contraceptives, progestin-only pills, the contraceptive implant, the levonorgestrel IUD, and the copper IUD all are classified as Category 1 (no restrictions on use); the contraceptive injection is classified as Category 2 (advantages generally outweigh theoretical or proven risks).5 However, certain drugs to treat CF, such as lumacaftor, might reduce effectiveness of hormonal contraceptives, including oral, injectable, transdermal, and implantable contraceptives.
Women with CF have a higher prevalence of osteopenia, osteoporosis, and fragility fractures than the general population; use of the contraceptive injection, which has been associated with small changes in bone mineral density, might be of concern.
Many medical conditions are associated with increased risk for adverse health events as a result of pregnancy, the 2016 MEC notes.
These conditions include: breast cancer; complicated valvular heart disease; diabetes (insulin dependent; with nephropathy, retinopathy, or neuropathy or other vascular disease; or of more than 20 years’ duration); endometrial or ovarian cancer; epilepsy; history of bariatric surgery within the past two years; gestational trophoblastic disease; hepatocellular adenoma and malignant liver tumors (hepatoma); peripartum cardiomyopathy; schistosomiasis with fibrosis of the liver; severe (decompensated) cirrhosis; sickle cell disease; solid organ transplantation within the past two years; stroke; systemic lupus erythematosus; thrombogenic mutations; and tuberculosis.5
REFERENCES
- American College of Obstetricians and Gynecologists. Contraceptive counseling. Position statement. Available at: http://bit.ly/2hFIgLc. Accessed Dec. 16, 2016.
- Teal SB, Ginosar DM. Contraception for women with chronic medical conditions. Obstet Gynecol Clin North Am 2007;34:113-126.
- Stancil SL, Miller M, Briggs H, et al. Contraceptive provision to adolescent females prescribed teratogenic medications. Pediatrics 2016;137:1-8.
- Champaloux SW, Tepper NK, Curtis KM, et al. Contraceptive use among women with medical conditions in a nationwide privately insured population. Obstet Gynecol 2015;126:1151-1159.
- Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR Recomm Rep 2016;65:1-103.
- Gatiss S, Mansour D, Doe S, Bourke S. Provision of contraception services and advice for women with cystic fibrosis. J Fam Plann Reprod Health Care 2009;35:157-160.
Few medical conditions are absolute contraindications to long-acting reversible contraceptive methods.
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